ANKLE INJURIES:

ANKLE SPRAIN

Saurab Sharma, MPT

Lecturer/ KUSMS

BPT 3rd Year

Overview

• Introduction

• Stability

• Impact of injury

• Diagnosis

• Clinical features

• Examination

• Management

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Introduction

• Incidence - 2.15 per 1000 person/ years in the general population.

• Highest incidence- between 15 and 19 years of age

• No difference between genders

• Half of all ankle sprains occur during athletic activity, eg: basketball (41.1%), football (9.3%), and soccer (7.9%)

• Ankle injuries account for 10% to 34% of all sport-related injuries, with lateral ankle sprain comprising 77% to 83% of these injuries

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Introduction• Lateral ankle sprains may occur with subtalar, medial,

and/or syndesmotic sprains

• High chances of chronic pain, instabilities, and limitation

in activities and participation and high recurrence rates.

Other structures involved are:

• Lateral subtalar ligaments; Nerve injury

• Fibular (peroneal) tendon injury

• Extensor and peroneal retinaculum injury

• Inferior tibiofiular ligament

• Osteochondral lesions of the talus or tibia

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Anterior Talofibular Ligament

• Extra-articular ligament

• Provides primary restraint to inversion movement when

the ankle is in a plantar-flexed position.

• 50% avulsion from Fibula; 50% mid substance tear

• Lower maximal load tolerance before failure compared to

other structures

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Stability of ankle

• Dynamic and static stability

• Dynamic stabilization of the ankle complex is dependent

on the adjacent musculatures and laterally includes the

fiularis (peroneus) longus and brevis.

• The tibialis anterior and extensor digitorum longus are

thought to eccentrically control ankle plantar flexion.

• Reflex reaction is slow to protect injury, but anticipatory

contraction may help prevent the injury

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Impact of injury

Injury to ankle ligaments may cause:

• Weakness and injury of local muscles

Weakness of remote muscles:

• Lumbar spine- erector spine

• Hip- Gluteus maximus, biceps femoris

Sensory changes can occur in the joint receptors and

cutaneous nerves, such as the sural nerve and distal

superficial peroneal nerve.

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CLINICAL COURSE

• rapid decrease in pain and improvement in function the

fist 2 weeks after the injury.

• 5% to 33% of patients continued to have pain at 1-year;

5% to 25% still experiencing pain after 3 years.

• Residual problems pain (30%), instability (20%), crepitus

(18%), weakness (17%), stiffness (15%), and swelling

(14%).

• Full recovery between 50% and 85% at approximately 3

years after the injury and seemed independent of sprain

severity.

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Clinical features

• Pain (rest and weight bearing)

• Swelling

• Redness, ecchymosis

• Instability

• Weakness

• Impaired proprioception and postural control

• Activity limitations and participation restrictions

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Risk Factors: Intrinsic

• The history of previous sprains

• Age

• ? Gender (younger female; older male)

• Physical characteristics (ie, height, weight, and body

mass index)

• Msculoskeletal characteristics (ie, balance,

proprioception, range of motion, strength, anatomic

alignment, and ligament laxity)

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Risk Factors: Extrinsic

• Use of external support; Footwares

• Type of Sport

• Level of competition

• Participation in neuromuscular training.

• Surface of play

• Inadequate warm up and cool downs

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Diagnosis: Ankle Sprain

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Diagnosis: Ankle instability

The Cumberland Ankle Instability Tool: 9-item

• The test-retest ICC was 0.96.

• Sensitivity and specificity of 85.5 and 82.6 respectively

• The Ankle Instability Instrument – 12 items

• Functional Ankle Instability Questionnaire- 10 items

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Differential Diagnosis

Ottawa Ankle Rules:

Radiographs are indicated if there was pain in the malleolar

zone and any of the following criteria are met:

(1) tenderness along the tip of the posterior edge of the

distal 6 cm of the lateral malleolus,

(2) tenderness along the medial malleolus, and/or

(3) An inability to bear weight for 4 steps.

(4) Pain in the mid-foot area

The Bernese ankle rules

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Differential Diagnosis

• Syndesmotic injury

• Cuboid syndrome

• Peroneal tendon tendinitis/tendinopathy

• Sensory nerve injury

• Medial collateral ligament ankle sprain

• Lisfranc fracture/dislocation

• Subtalar sprain

• Spring or bifurcate ligament injury

• Achilles tendon rupture

• Lateral talar process injury

• Anterior process of the calcaneus injury

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Examination: Outcome measures

• The Foot and Ankle Ability Measure (FAAM)

• The Foot and Ankle Disability Index (FADI)

• Lower Extremity Functional Scale (LEFS)

• The Chronic Ankle Instability Scale

• The Sports Ankle Rating System

• The Ankle Joint Functional Assessment Tool

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Examination: Activity limitation and

participation restriction measures

• side hop

• 6-m crossover hop

• 40-m walk time; 40-m run time

• Figure-of-eight run

• Single-limb forward hop

• Crossover hop

• Stair hop

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Examination: Activity limitation and

participation restriction measures

• When evaluating a patient in the post-acute period

following a recent or recurring lateral ankle sprain,

assessment of activity limitation, participation restriction,

such as single-limb hop tests that assess performance

with lateral movements, diagonal movements, and

directional changes.

(GRADE B RECOMMENDATION)

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Examination: Physical impairment

• Swelling

• ROM- ankle joint, subtalar joint

• Ankle and foot pronation and supination

• Anterior drawer test

• Talar tilt test

• Isokinetic Muscle Strength of Inversion and Eversion

• Single-Limb Balance

• Star Excursion Balance Test

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Measurement of swelling

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ROM

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Special tests

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Single limb balance test (SLBT)

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Eyes open and eyes closed for 1 minutes each

Star excursion balance test (SEBT)

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Interventions

• ACUTE/ PROTECTED MOTION PHASE

OF REHABILITATION

• PROGRESSIVE LOADING/ SENSORIMOTOR

TRAINING PHASE OF REHABILITATION

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ACUTE/ PROTECTED MOTION PHASE

• Early weight bearing with support – I

• External support - I

• Cryotherapy – I

• Manual Therapy – II

• Pulsed Diathermy – II

• Stimulation – II

• Laser II

• Ultrasound- I (no benefit)

• Therapeutic exercises- I

(active range-of-motion exercises, and progressive resistive

exercises incorporating progressive weight bearing)

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PROGRESSIVE LOADING/

SENSORIMOTOR TRAINING PHASE• Manual Therapy– I

Clinical prediction rule to predict likely rapid responders

to manual therapy. Subjects meeting at least 3 of 4 criteria

were up to 95% likely to respond favorably to intervention

within 3 treatment sessions.

• Worse symptoms with standing,

• Worse symptoms in the evening,

• Navicular drop test of 5 mm or more, and

• Hypomobility of the distal tibiofiular joint.

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PROGRESSIVE LOADING/

SENSORIMOTOR TRAINING PHASETherapeutic Exercise and Activities- I

• ROM exercises

• Weight-bearing functional exercises

• Single-limb balance activities using unstable surfaces

• Exercises to improve mobility, strength, coordination, and

postural control

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Scope for Self learning:

• Refining your assessment skills

• Outcome tools related to ankle and foot

• Functional assessment tools

• Special tests

• Other differential diagnoses

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References

• Martin et al. Ankle Stability and Movement Coordination

Impairments: Ankle Ligament Sprains Clinical Practice Guidelines

Linked to the International Classification of Functioning, Disability and

Health From the Orthopaedic Section of the American Physical

Therapy Association. J Orthop Sports Phys Ther. 2013;43(9):A1-

A40. doi:10.2519/jospt.2013.030

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